Drinking Water and Weight Management
Stookey, Jodi D. PhD
Jodi D. Stookey, PhD, is assistant staff scientist at Children's Hospital Oakland Research Institute, California. Dr Stookey is a nutrition epidemiologist focused on long-term effects of hydration on chronic disease.
Dr Stookey has received a research grant and speaker honorarium from Danone Waters R&D.
Correspondence: Jodi D. Stookey, PhD, Children's Hospital Oakland Research Institute, 5700 Martin Luther King Jr Way, Oakland, CA 94609 (firstname.lastname@example.org).
This review summarizes the evidence base for recommending drinking water for weight management. Crossover experiments consistently report that drinking water results in lower total energy intake when consumed instead of caloric beverages, because individuals do not eat less food to compensate for calories in beverages. Crossover experiments also consistently report that drinking water results in greater fat oxidation compared with other beverages, because drinking water does not stimulate insulin. In intervention studies, advice to drink water is associated with reduced weight gain in children and greater weight loss in dieting adults. Although gaps in knowledge remain about specific effects of drinking water on weight loss in children and obesity prevention in adults, there is a strong evidence base for recommending drinking water for weight management
The public is confronted with conflicting messages about weight management. Beverage guidelines are no exception. Not drinking caloric beverages is, for example, described as essential for weight loss,1 while drinking noncaloric beverages, such as water, is described as ridiculous for weight loss.2 Moreover, the scientific literature recommends drinking water and other beverages including low-fat milk and small quantities of fruit juice,3-5 at the same time as criticizing beverage recommendations as lacking an adequate evidence base.6-9
The paragraphs that follow describe a strong evidence base for recommending drinking water for weight management. Accumulated data from the most rigorous of study types, crossover experiments, and randomized and controlled trials indicate that drinking water results in lower total energy intake and higher rates of fat oxidation than other beverages. Advice to drink water is associated with reduced weight gain in children and weight loss in dieting adults.
Drinking Water Results in Lower Total Energy Intake
In crossover experiments, drinking water consistently results in lower total energy intake than caloric beverages.10-17 The effect is attributed to a lack of compensation for the calories in beverages. Individuals do not eat less food to compensate for beverage calories (Figure). The excess energy intake associated with caloric beverages is approximately equivalent to the calorie content of the beverage.18-23 Although drinking water contains 0 cal, caloric beverages contain on average 200 cal (about 838 kJ) per serving. Except in milk, calories from beverages mainly come from carbohydrates.
Figure. Energy intak...Image Tools
Although some very young children (<4 years) compensate for beverage calories by eating less food,24,25 the ability to compensate decreases with age,26 perhaps because of family environment, restrictive child-feeding practices, parent role models, or social cues about food portion size.26 Long-term crossover studies furthermore indicate that compensation for calories in beverages does not improve over time.27-29
Although some data suggest that noncaloric "diet" beverages can limit total energy intake like drinking water,14 other data indicate less caloric benefit.27,30 Aspartame-sweetened drinks may increase food intake.31
Drinking Water Results in Greater Rates of Fat Oxidation
Fat oxidation is maximal when blood insulin levels are low. Insulin inhibits the rate-limiting enzymes (eg, hormone-sensitive lipase, acylcarnitine transferase, and pyruvate carboxylase) that breakdown triglyceride into free fatty acids, transport free fatty acids into the mitochondria, and commit them to oxidation by the tricarboxylic acid/Krebs cycle.32,33
Drinking water does not contain macronutrients like other beverages and so does not trigger insulin like other beverages. The glycemic index of drinking water is 0, whereas that of milk is 30 to 40, that of juices is 40 to 60, and that of sugar-containing soft drinks and sports drinks is 50 to 80.34 The lower glycemic response to drinking water translates into greater rates of fat oxidation, because even small increases in insulin, such as those observed after fructose intake,35 inhibit body fat breakdown and fat oxidation.
Decades of crossover experiments consistently demonstrate greater rates of fat oxidation when drinking water is consumed instead of a caloric beverage, before or during low-to-moderate intensity exercise36-51 (Table). Across studies, fat oxidation is approximately 40% greater after water than after a caloric beverage.52 Under some study conditions, such as jogging after an overnight fast, reported rates of fat oxidation are as much as 0.5 g/min higher after drinking water than after a caloric beverage.
Table. Effects of Dr...Image Tools
Fat oxidation is depressed after food intake by postprandial increases in insulin. The choice of beverage paired with a meal, however, can have a major impact on the length of time that fat oxidation is depressed. Drinking water with a meal can restore blood insulin levels and rates of fat oxidation to premeal values approximately 2 hours earlier than intake of a caloric beverage with the same meal.53-55 Intake of 500 to 600 kcal (about 2000-2500 kJ) of carbohydrate can depress fat oxidation for 6 hours after ingestion.56 Noncaloric, "diet" drinks may not restore postprandial fat oxidation like water, because sweet taste can stimulate insulin independent of calories.57,58
In children, interventions that promote drinking water prevent weight gain
Six intervention trials have reported the effects of drinking water promotion on weight change in children59-63 and adolescents.64 Five of 6 interventions combined advice to drink water with other beverage change recommendations.59,60,62,63 One intervention combined advice to drink water with installation of water fountains, distribution of water bottles, instruction about the water needs of the body, and teacher-sanctioned water-bottle filling times during the school day.61
Four of 6 studies randomized either schools59,60,62 or individuals64 to the beverage change intervention or control. Two studies compared change in schools in an intervention community versus change in schools in a control community.61,63 The school-based studies recruited representative samples of school-aged children generally (ie, all children attending the schools). The randomized study designs and representative study samples allow inferences to be drawn about exposure versus nonexposure to the intervention for weight management in the general pediatric population.
The results of 5 of 6 studies indicated that interventions that promote drinking water reduce excess weight gain. In the study by Ebbeling et al,64 body mass index (BMI) increased by 0.21 kg/m2 in the control group, but only 0.07 kg/m2 in the intervention group. James et al60 reported an increase in the prevalence of overweight of 7.5% in the control group, and no change in the intervention group (−0.2%). Taylor et al63 reported an increase in BMI z score in normal-weight children in the control group, no change in BMI z score in overweight children in the control group, and no change in normal-weight or overweight children in the intervention group. In the study by Foster et al,59 the incidence of overweight over 2 years was 14.9% in control schools, but 7.5% in intervention schools. Finally, Muckelbauer et al61 and Taylor et al63 reported an increase in the prevalence of overweight from 25.9% to 27.8% in the control group and no change (23.4%-23.5%) in the intervention group. Given the randomized nature of these studies, the consistent prevention of weight gain across studies indicates that exposure to advice to drink water (with or without other beverage change or health promotion advice) can reduce weight gain in the general pediatric population.
In the study where BMI increased in both the control and intervention groups, 4-fold increases in juice intake counterbalanced decreases in sugar-sweetened beverage intake.62 The null finding is consistent with results of another intervention trial (that did not promote drinking water), where changes in milk intake negated decreases in sweetened caloric beverage intake.65 Excess calories from milk and 100% juice are associated with weight gain in children.66,67
The intervention trials in children are informative about weight maintenance/gain, but not weight loss. They focus on representative samples of children, as opposed to selected samples of overweight children, motivated to lose weight. The studies in children do not involve conditions that promote the breakdown and oxidation of body fat (ie, increased time spent fasting or exercising at <70% V˙O2 max).
In Adults Following Hypocaloric Diets, Drinking Water Is Associated With Weight Loss
Two intervention studies report the effects of drinking water promotion on weight loss in adults. Both studies involve restricted samples of overweight individuals, motivated to diet and consuming hypocaloric diets.
Dennis et al19 randomized 48 overweight or obese men and women to a hypocaloric diet plus 500 mL water at each meal, or to a hypocaloric diet only (control). The hypocaloric diet included 1200 kcal/d (about 5000 kJ/d) for women and 1500 kcal/d (about 6200 kJ/d) for men and followed US department of Agriculture pyramid guidelines. Intake of caloric beverages was discouraged. Weight loss after 12 weeks was approximately 2 kg greater in the water group compared with the control group.
Secondary analyses of data from the Stanford A to Z Study weight loss intervention focus on 155 overweight premenopausal women who reported drinking less than 1 L/d water before beginning 1 of 4 popular weight-loss programs (Atkins, Zone, LEARN, and Ornish).68 In general, the 4 programs recommend drinking 1 L/d or more water and limited/no intake of caloric beverages. After 2 months of diet classes, study participants in all 4 diet groups reported higher water intake and lower caloric beverage intake. Intake of 1 L/d or more drinking water was associated with significantly greater weight loss in all 4 diet groups, independent of change in diet composition and physical activity.
In summary, accumulated data from studies of the highest, most rigorous quality indicate that drinking water prevents excess total energy intake and promotes fat oxidation compared with caloric beverages. Drinking water instead of caloric beverages could reduce total energy intake of US children and adults by at least 10%.69,70
Although data from long-term, randomized interventions are still needed to confirm and characterize the effects of drinking water on weight loss in overweight children and obesity prevention in the general adult population, there is a strong evidence base for recommending drinking water for weight management.
1. Atkins R. Dr. Atkins' NEW Diet Revolution
. New York: Avon Books Inc; 1992.
3. Krebs NF, Jacobson T. Prevention of pediatric overweight and obesity. Pediatrics
4. American Dietetic Association. Position of the American Dietetic Association: nutrition guidance for healthy children ages 2 to 11 years. J Am Diet Assoc
5. Popkin BM, Armstrong LE, Bray GA, Caballero B, Frei B, Willett WC. A new proposed guidance system for beverage consumption in the United States. Am J Clin Nutr
6. Forshee RA, Anderson PA, Storey ML. Sugar-sweetened beverages and body mass index in children and adolescents: a meta-analysis. Am J Clin Nutr
7. Gibson S. Sugar-sweetened soft drinks and obesity: a systematic review of the evidence from observational studies and interventions. Nutr Res Rev
8. Marr L. Soft drinks, childhood overweight, and the role of nutrition educators: let's base our solutions on reality and sound science. J Nutr Educ Behav
9. Allison DB, Mattes RD. Nutritively sweetened beverage consumption and obesity, the need for solid evidence on a fluid issue. JAMA
10. Almiron-roig E, Drewnowski A. Hunger, thirst and energy intakes following consumption of caloric beverages. Physiol Behav
11. Beridot-Therond ME, Arts I, Fantino M, DeLaGueronniere V. Short-term effects of the flavour of drinks on ingestive behaviours in man. Appetite
12. Canty DJ, Chan MM. Effects of consumption of caloric vs noncaloric sweet drinks on indices of hunger and food consumption in normal adults. Am J Clin Nutr
13. Cecil JE, Palmer CNA, Wrieden W, et al. Energy intakes of children after preloads: adjustment, not compensation. Am J Clin Nutr
14. Della Valle DM, Roe LS, Rolls BJ. Does the consumption of caloric and non-caloric beverages with a meal affect energy intake? Appetite
15. Flood JE, Roe LS, Rolls BJ. The effect of increased beverage portion size on energy intake at a meal. J Am Diet Assoc
16. Hagg A, Jacobson T, Nordlund G, Rossner S. Effects of milk or water on lunch intake in preschool children. Appetite
17. King NA, Appleton K, Rogers PJ, Blundell JE. Effects of sweetness and energy in drinks on food intake following exercise. Physiol Behav
18. Almiron-Roig EDA. Hunger, thirst, and energy intakes following consumption of caloric beverages. Physiol Behav
19. Dennis EA, Dengo AL, Comber DL, et al. Water consumption increases weight loss during a hypocaloric diet intervention in middle aged and older adults. Obesity
20. Harper A, James A, Flint A, Astrup A. Increased satiety after intake of a chocolate milk drink compared with a carbonated beverage, but no difference in subsequent ad libitum lunch intake. Br J Nutr
21. Wilson JF. Preschool children maintain intake of other foods at a meal including sugared chocolate milk. Appetite
22. Wilson JF. Does type of beverage affect lunchtime eating patterns and food choice by preschool children? Appetite
23. Wilson JF. Lunch eating behavior of preschool children: effects of age, gender and the type of beverage served. Physiol Behav
24. Birch LL, Deysher M. Caloric compensation and sensory specific satiety: evidence for self regulation of food intake by young children. Appetite
25. Birch LL, McPhee L, Sullivan S. Children's food intake following drinks sweetened with sucrose or aspartame: time course effects. Physiol Behav
26. Johnson SL. Improving preschooler's self-regulation of energy intake. Pediatrics
27. Stookey JD, Constant F, Gardner CD, Popkin BM. Replacing sweetened caloric beverages with drinking water is associated with lower energy intake. Obesity (Silver Spring, Md)
28. VanWymelbeke V, Beridot-Therond ME, DeLaGueronniere V, Fantino M. Influence of repeated consumption of beverages containing sucrose or intense sweeteners on food intake. Eur J Clin Nutr
29. Mrdjenovic G, Levitsky DA. Nutritional and energetic consequences of sweetened drink consumption in 6- to 13-year old children. J Pediatr
30. Wang YC, Ludwig DS, Sonneville K, Gortmaker SL. Impact of change in sweetened caloric beverage consumption on energy intake among children and adolescents. Arch Pediatr Adolesc Med
31. Lavin JH, French SA, Read NW. The effect of sucrose- and aspartame-sweetened drinks on energy intake, hunger and food choice of female, moderately restrained eaters. Int J Obes Relat Metab Disord
32. Paterson CR. Essentials of Human Biochemistry
. Edinburgh: Churchill Livingstone; 1987.
33. Nutritional Biochemistry and Metabolism
. New York: Elsevier; 1991.
34. Foster-Powell K, Holt SHA, Brand-Miller JC. International table of glycemic index and glycemic load values: 2002. Am J Clin Nutr
35. Horowitz JF, Mora-Rodriguez R, Byerley LO, Coyle E. Lipolytic suppression following carbohydrate ingestion limits fat oxidation during exercise. Am J Physiol Endocrinol Metab
36. Kirwan JP, O'Gorman DJ, Cyr-Campbell D, Campbell WW, Yarasheski KE, Evans WJ. Effects of a moderate glycemic meal on exercise duration and substrate utilization. Med Sci Sports Exerc
37. Kirwan JP, O'Gorman D, Evans WJ. A moderate glycemic meal before endurance exercise can enhance performance. J Appl Physiol
38. Wallis GA, Dawson R, Achten J, Webber J, Jeukendrup A. Metabolic response to carbohydrate ingestion during exercise in males and females. Am J Physiol Endocrinol Metab
39. Riddell MC, Bar-Or O, Schwarcz HP, Geigenhauser GJF. Substrate utilization in boys during exercise with [13
C]-glucose ingestion. Eur J Appl Physiol
40. Riddell MC, Bar-Or O, Wilk B, Parolin ML, Heigenhauser GJF. Substrate utilization during exercise with glucose and glucose plus fructose ingestion in boys ages 10-14y. J Appl Physiol
41. Riddell MC, Bar-Or O, Hollidge-Horvat M, Schwarcz HP, Heigenhauser GJF. Glucose ingestion and substrate utilization during exercise in boys with IDDM. J Appl Physiol
42. Adopo E, Peronnet F, Massicotte D, Brisson GR, Hillaire-Marcel C. Respective oxidation of exogenous glucose and fructose given in the same drink during exercise. J Appl Physiol
43. Massicotte D, Peronnet F, Adopo E, Brisson GR, Hillaire-Marcel C. Metabolic availability of oral glucose during exercise: a reassessment. Metabolism
44. Jentjens RLPG, Achten J, Jeukendrup A. High oxidation rates from combined carbohydrates ingested during exercise. Med Sci Sports Exerc
45. Jentjens RLPG, Jeukendrup A. High rates of exogenous carbohydrate oxidation from a mixture of glucose and fructose ingested during prolonged cycling exercise. Br J Nutr
46. Jentjens RLPG, Moseley L, Waring RH, Harding LK, Jeukendrup A. Oxidation of combined ingestion of glucose and fructose during exercise. J Appl Physiol
47. Jentjens RLPG, Shaw G, Birtles T, Waring RH, Harding LK, Jeukendrup A. Oxidation of combined ingestion of glucose and sucrose during exercise. Metab Clin Exp
48. Jentjens RLPG, Underwood K, Achten J, Currell K, Mann CH, Jeukendrup A. Exogenous carbohydrate oxidation rates are elevated after combined ingestion of glucose and fructose during exercise in the heat. J Appl Physiol
49. Del Coso J, Estevez E, Mora-Rodriguez R. Caffeine effects on short-term performance during prolonged exercise in the heat. Med Sci Sports Exerc
50. Jentjens RLPG, Venables MC, Jeukendrup A. Oxidation of exogenous glucose, sucrose, and maltose during prolonged cycling exercise. J Appl Physiol
51. Jung W, Yamasaki M. Effect of pre-exercise carbohydrate ingestion on substrate consumption in persons with spinal cord injury. Spinal Cord
52. Stookey JD. Drinking water results in greater fat oxidation than beverages that contain carbohydrate during low to moderate intensity exercise. Poster presented at Experimental Biology, New Orleans, April 18-22, 2009.
53. Elmstahl HGML, Bjorck IME. Milk as a supplement to mixed meals may elevate postprandial insulinaemia. Eur J Clin Nutr
54. Febbraio MA, Chiu A, Angus DJ, Arkinstall MJ, Hawley JA. Effects of carbohydrate ingestion before and during exercise on glucose kinetics and performance. J Appl Physiol
55. Ostman EM, Elmstahl HGML, Bjorck IME. Inconsistency between glycemic and insulinemic responses to regular and fermented milk products. Am J Clin Nutr
56. Montain SJ, Hopper MK, Coggan AR, Coyle E. Exercise metabolism at different time intervals after a meal. J Appl Physiol
57. Just T, Pau HW, Engel U, Hummel T. Cephalic phase insulin release in healthy humans after taste stimulation. Appetite
58. Tonosaki K, Hori Y, Shimizu Y, Tonosaki K. Relationships between insulin release and taste. Biomed Res
59. Foster GD, Sherman S, Borradaile KE, et al. A policy-based school intervention to prevent overweight and obesity. Pediatrics
60. James J, Thomas P, Cavan D, Kerr D. Preventing childhood obesity by reducing consumption of carbonated drinks: cluster randomized controlled trial. BMJ
61. Muckelbauer R, Libuda L, Clausen K, Toschke AM, Reinehr T, Kersting M. Promotion and provision of drinking water in schools for overweight prevention: randomized, controlled cluster trial. Pediatrics
62. Sichieri R, Trotte AP, deSouza RA, Veiga GV. School randomized trial on prevention of excessive weight gain by discouraging students from drinking sodas. Public Health Nutr
63. Taylor RW, McAuley KA, Barbezat W, Strong A, Williams SM, Mann JI. APPLE Project: 2-y findings of a community-based obesity prevention program in primary school-age children. Am J Clin Nutr
64. Ebbeling CB, Feldman HA, Osganian SK, Chomitz VR, Ellenbogen SJ, Ludwig DS. Effects of decreasing sugar-sweetened beverage consumption on body weight in adolescents: a randomized controlled pilot study. Pediatrics
65. Albala C, Ebbeling CB, Cifuentes M, Lera L, Bustos N, Ludwig DS. Effects of replacing the habitual consumption of sugar-sweetened beverages with milk in Chilean children. Am J Clin Nutr
66. Berkey CS, Rockett HR, Willett WC, Colditz GA. Milk, dairy fat, dietary calcium and weight gain: a longitudinal study of adolescents. Arch Pediatr Adolesc Med
67. Dennison BA. Fruit juice consumption by infants and children: a review. J Am Coll Nutr
68. Stookey JD, Constant F, Popkin BM, Gardner C. Drinking water is associated with weight loss in overweight dieting women independent of diet and activity. Obesity (Silver Spring, Md)
69. Wang YC, Bleich SN, Gortmaker SL. Increasing caloric contribution from sugar-sweetened beverages and 100% fruit juices among US children and adolescents, 1988-2004. Pediatrics
70. Popkin BM, Barclay DV, Nielsen SJ. Water and food consumption patterns of US adults from 1999 to 2001. Obes Res
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